Pediatric Intake Form - Carabasi Chiropractic Center

Carabasi Chiropractic Center - PEDIATRIC INTAKE FORM
Date:*

MonthDayYear
Date
Child's Name*

First NameMiddle NameLast Name
Preferred Name:
Street Address:*
City / State / Zip:*
Birth Date:*

MonthDayYear
Date
Age*
Sex*

MaleFemale
Number of Siblings:*
Sibling(s) Names & Ages*
Parents' Names:*
First and Last for Mom and Dad
Parent completing this form*

First NameLast Name
Best Contact Cell Phone, for parent completing form:*
Alternate Phone:
Email for parent competing this form:*
example@example.com
Who can we thank for referring you or how did you hear about us?*
What is your reason for seeking chiropractic care?*
When did this begin? (If applicable)*
Are there any major injuries and/or surgeries we should know about?*
What is this affecting that is MOST important in your child's life? (List all that apply)*
Has your child seen any other providers for this condition? (List all that apply)*
Has your child seen a chiropractor before?*

YesNo
If yes, how long ago?
If yes, Clinic/Doctor Name:
What is your reason for the change? (If applicable)
On a scale of 1 to 10, what is your level of commitment to your child's health?*

12345678910
Explain:*
What health goal, if your child were to complete or accomplish it, would have the greatest impact?*
HEALTH CONCERNS*

Anxiety/DepressionFatigue/Sleep IssuesAsthma/Chronic BronchitisConstipation/DiarrheaColic/Acid RefluxNausea/VomitingDiabetesBack/Neck Pain/StiffnessBed WettingDifficulty Gaining WeightEar or Other InfectionsOverweightHeadachesFrequent SicknessADD/ADHDLearning DisordersDetachment/DistanSinus Troubles/AllergiesIrritability/NervousAutism/Asperger'sNoneOther
Explain any boxes checked above:*
Is there anything regarding your child's current condition you feel the doctor should know? (Explain)*
MEDICATIONS*

Anxiety/DepressionMigraine/HeadacheAsthmaAcid RefluxPain NarcoticsADD/ADHDAntibioticsDigestiveNoneOther - List any other medications below
Explain any checked medications:*
VITAMINS/SUPPLEMENTS*

Multi-VitaminFIsh Oil/Omega-3Vitamin D3Other - List any other medications below
Explain any checked vitamins or supplements:*
PRENATAL HISTORY SECTION
Location of birth:*

HomeBirthing CenterHospitalOther
Did any of the following happen during delivery:*

C-section deliveryDoctor pulled or twisted babyAnesthesiaLabor was inducedForceps/vacuum extractionPremature deliverySpecial medical procedures/tests
Describe any of the above plus any additional complications experienced during delivery:*
During pregnancy, was there any use of drugs, tobacco, alcohol, and/or medications? If yes, please list:*
Did the mother experience any illness while pregnant?*

YesNo
If yes, explain:
For the mother, do you have any physical disabilities?*

YesNo
If yes, explain:
Birth weight:*
Birth length:*
APGAR scores (if remembered):*
Can enter "Don't recall" if you can't remember
Ultrasound used during pregnancy?*

YesNo
If yes, number of times:
Was the baby breastfed?*

YesNo
If yes, how long:
Was the baby formula-fed?*

YesNo
If yes, how long:
What age did you introduce Solids:*
What age did you introduce Cow's milk:*
Does your child exercise daily?*

YesNo
How much?*
Does your child drink soda?*

YesNo
How much/often?*
Does your child have a positive self-esteem or self-image?*

YesNo
Does your child watch more than an hour of TV or screens per day?*

YesNo
How much?*
Does your child eat balanced meals?*

YesNo
Does your child experience prolonged sadness?*

YesNo
If yes, Explain:
Does your child have difficulty sleeping?*

YesNo
If yes, Explain:
Does your child play video games?*

YesNo
If yes, How much?
The National Safety Council reports approximately 50% of children fall head first from a high place during their first year of life (bed, changing table, stairs, etc)Was this the case for your child?*

YesNo
Explain:
Has your child ever been hospitalized or had surgery?*

YesNo
Explain:
Does your child have difficulty interacting with others?*

YesNo
Explain:
Have you noticed that your child is nervous, twitches, shakes, or exhibits rocking behavior?*

YesNo
Explain:
Has your child been involved in any high impact/contact sports? (soccer, football, martial arts, cheerleading, etc)*

YesNo
Please list:
Are you aware of any food allergies or intolerance?*

YesNo
Explain:
Has your child received all recommended vaccinations?*

YesNo
Explain:
Please rate stress levels related to SCHOOL on a scale of 1 -10 (10 being highest)*
Please rate PERSONAL stress levels on a scale of 1-10 (10 being highest)*
I, First Name Last Name , the give Carabasi Chiropractic Center permission to examine, x-ray (if necessary) and treat (Minor) First Name Last Name , whose date of birth is: Date of Birth .
Signature

Clear
Date

MonthDayYear
Date
PATIENT HIPPA CONSENT FORM

Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to define situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days with a request. You may request to view charges to your records. In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice and its staff.

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding protectedhealth information. I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow my up with multiple healthcare providers who may be involved in that treatment directly or indirectly, obtain payment from third party payers, and conduct normal healthcare operations such as quality assessments and physician's certificates. I have read and understand your Notice of Privacy Practices. A more complete description can be requested. I also understand that I can request, in writing, that yourestricthowmy personal information is used and disclosed.
Print Patient Name:*
Your Relationship to Patient :*
Date:*

MonthDayYear
Date
Signature:*

Clear
FINACIAL POLICY

Our goal is to provide the highest quality of healthcare possible for our patients. In order to achieve this goal, we need your commitment as well.

We urge our patients to follow the doctor's recommendations for care. Please keep your appointments as scheduled or call our office within 24 hours to make any changes. In order to attain the level of achievement we both desire, care must be followed.

I authorize Carabasi Chiropractic Center to release any information deemed appropriate concerning my physical condition to any insurance company, attorney, or adjuster in order to process any claim for reimbursement of charges incurred by me. I authorize the direct payment to Carabasi Chiropractic Centerof any sum I now or hereafter owe by my attorney out of settlement of my case, and by any insurance company obligated to make payment to me or Carabasi Chiropractic Centerbased in whole or in part upon themadefor charges services received. I hereby appoint Carabasi Chiropractic Center authority to endorse and cash checks, drafts, or money orders made payable to the undersigned or as co-payee with this clinic for payments due for services rendered on behalf of the undersigned by Carabasi Chiropractic Center.

In order to file your claims in a timely manner, we need current, accurate insurance information for you and your dependents. We will do our best to confirm your eligibility and level of insurance coverage for care; however, it is ultimately your responsibility to know your own insurance benefits in relation to what your insurance covers and what it doesn't. Should your insurance carrier determine that any or all of our services are ineligible for payment, you will be billed directly for those services.

Late payment for non-coverage, deductible, and co-payment may be subject to an 18% annual finance charge, which will be added monthly to that account. If you have any questions about our financial policies, please ask to speak to our financial officer. If you need to make special arrangements, please ask. We will never deny care to anyone based solely on ability to pay. We will do everything possible to meet your financial needs.

Advanced Beneficiary Notice of NON-Coverage (ABN Your health insurance does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect your health insurance will not pay for items and services such as your initial visit and any chiropractic care deemed maintenance or wellness care by your carrier (as well as other items that may arise the infuture Signing below signifies that you want these items and services, but understand that they will not be billed to your insurance company. Therefore, you are responsible for payment and cannot appeal to your insurance carrier as they were not submitted and/or billed to them. This notice gives our opinion, not an official Medicare or other insurance carrier's decision. If you have other questions, please ask our front desk. Signing below means that you have received and understand this notice.
Date:*

MonthDayYear
Date
Parent/Guardian Signature :*

Clear
AUTHORIZATION FOR CARE

I hereby authorize doctors and staff at Carabasi Chiropractic Center to treat my child as deemed appropriate. At Carabasi Chiropractic Center,we do not diagnose or treat any disease or condition other than vertebral subluxation and the doctor/clinic will not be held responsible for any pre-existing medical conditions.

I certify that the above information is correct to the best of my knowledge. I will not hold any doctor or any staff member of Carabasi Chiropractic Center responsible for any errors or omissions that I may have made in the completion of this form. Chiropractic, as well as all other types of health care, is associated with potential risks in the delivery of treatment. While chiropractic treatment is remarkably safe, you need to be informed about the potential risks related to treatment to allow you to be fully informed before consenting to treatment. Please inquire if you have further questions. Chiropractic is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, condition, or disease as a result of treatment in this office. An attempt to provide you with the very best care is our goal, and if the results are not acceptable, we will refer you to another provider who we feel can further assist you.
Date:*

MonthDayYear
Date
Parent/Guardian Signature:*

Clear
Should be Empty:

Carabasi Chiropractic Center - PEDIATRIC INTAKE FORM

PRENATAL HISTORY SECTION